The Sexual Heatmap

When RxISK launched a Sex Zone, we press released it. We wanted as many people as possible to go to the Zone, explore what was there among the 4.3 million FDA reports we give away for free, and get word out about the site and especially that here was a site that could be used to report about things that doctors rarely report about.

A site with a difference. We intend to put local knowledge in local hands so for instance if a particular sexual fetish on a statin is happening in Madison but not Milwaukee, or exhibitionism on a fluoroquinolone in Cologne but not Frankfurt, our Heatmaps will show this. We think people in Madison and Milwaukee, or Cologne and Frankfurt, faced with these differences are best placed to work out what is going on than regulators, academics from elsewhere or companies.

But in this arena even the innocent use of the word Heatmap for sexual effects on drugs which might include increased libido can be loaded.

The effects of drugs

Calling some sexual effects of drugs adverse effects is a close to disastrous framing of the issues. If someone on an antidepressant switches from being heterosexual to homosexual and we say that they have had an adverse effect, we risk getting the Gay and Lesbian community up in arms. They might call for a boycott of RxISK. At least this is what we were told. My hunch is the Gay and Lesbian communities will be a lot more relaxed about this than the straight community.

The term adverse effects is plain wrong for other reasons. SSRIs for instance have much clearer, and more consistent and obvious effects on sex than on mood. When they were brought to market in the 1980s it was still impossible to talk about sex. The depression market was a lot bigger, and so they became antidepressants that had side effects on sexual functioning. It is much more accurate to say they have effects on sexual functioning and side effects on mood. It was a boardroom decision by businessmen – not RxISK’s call – that makes any sexual effects into side effects or adverse effects rather than just effects.

Not an ivory tower

So far so academic. But something proverbial hit the fan when the press release included the fact that there were early and consistent reports that antidepressants could change sexual orientation from homosexuality to heterosexuality. Impossible we were told. You will lose all credibility making these claims.

The first report of this effect is tucked away in the very first English language article on the discovery of the antidepressant effects of imipramine by Roland Kuhn. Imipramine we now know is a potent serotonin reuptake inhibitor. Kuhn was a country doctor, more a psychotherapist than a psychopharmacologist. He was conservative in attitude. His explanation for what was going on was that some homosexual behaviors stemmed from depression and relieving this helped “normalize” other behaviors. He didn’t celebrate the issue but he may have been pleased – in line with dominant thinking at that time.

Much more controversially, fifty years later, in 2009 Joseph Nicolosi claimed that Lexapro straightened out a homosexual patient of his. Subject to close scrutiny, this claim fell apart.

The year after that a Nature article on the manipulation of the serotonin system in rats seemed to give some credence to the possibility that tweaking the serotonin system could change orientation.

The RxISK press release said if a change in orientation can happen we have absolutely no reason to believe that antidepressants will only push people one way – from homosexuality to heterosexuality.

We were told stories aren’t evidence. Extraordinary claims need extraordinary evidence. We don’t have any physiological basis for an effect like this.

Reverse stigma

Let’s back up for a moment. One of the most powerful RxISK stories posted centered on Anne-Marie’s efforts to get to grips with her hunch that the antidepressant she was on was causing her to be “alcoholic”. She was accused of typical alcoholic denial. A confusing switch from one SSRI to another that left the problem in place made it much harder for her to win the argument. Finally she proved her point.

Since her post hundreds of people have posted comments or reported in confirming just what she said – these are really worth reading. We went back to search the academic literature for a basis for her claims and this has led to a peer-reviewed article in press on the issue.

Anne-Marie’s was a compelling story and an extraordinary claim. The conventional wisdom still is that many alcoholics drink because they are depressed. Clear up the mood disorder and you may stop the abusive drinking. Or else their alcohol intake will lead to depression that needs treatment with antidepressants. Very few people buy the idea that the drugs can cause the problem for some.

When Anne-Marie took the “good news” to her AA group she met anger and hostility – you will never be cured while you think like this. When she attempted to post details on alcohol on probation sites she has had her posts taken down and has been threatened with stiffer action.

She is suffering from reverse stigmatization. The stigma of being someone who is cured of something you are not supposed to be cured of or cured in a way that is unsanctioned.

Individuals can’t be averaged

No one it seems likes “simple” complexity. When I was a medical student, we ran a practical where 10 of us took a beta-blocker. We were to monitor blood pressure, heart rate and other variables. They should all have dropped but one woman’s heart rate rose. The group behaved just as the books said. What the books don’t say is these averages may be completely wrong for individuals.

I have seen the same thing over and over again – in neuroendocrine studies, fMRI studies, cognitive function testing, where the processes are not under conscious control and subjects cannot fake the outcomes.

Companies know this well. Lilly used it to counter perceptions of sexual dysfunction on Prozac. An “adverse” effect reported to the company soon after marketing that involved a woman who apparently had an orgasm every time she yawned somehow achieved wide circulation.

It turns out that those saying orientation can’t change fully accept that some heterosexuals come out as homosexuals – they are less clear about the opposite. What’s going on they say is that people use the cover of a pill as an excuse for coming out – they don’t truly change orientation.

Social beauty and the biological beast

A very nuanced interplay between social and biological factors was laid out in response to 50 Shades of Mirtazapine by Ned Shorter. Shorter’s argument brings out an important point. Sexual fetishes were not reported before Leopold von Sader Masoch’s Venus in Furs in 1870, and so this option would not have been available to someone on an SSRI before 1870. The option is likely to be all too available to anyone on an SSRI with the release of Polanski’s movie version of Venus in Furs later this year.

More generally profound changes in the notion of identity took place in the nineteenth century and these changed ideas of sexual orientation in a way we have to take into account when we say a drug could cause a change in orientation.

But the biological changes a drug induces are likely to be the same in an Ancient Greek as a modern New Yorker. The fact that the New Yorker has an outlet in fetishism that the Greek didn’t have – is just that an outlet. Over 50% of Ancient Greeks on an SSRI would have had sexual dysfunction just as 50% of New Yorkers do today. To deny “real” and perhaps fundamental effect on sexual functioning on this basis doesn’t make sense. An Ancient Greek might not have had the example of school shootings to shape his behavior but the agitation the drugs produce would likely still lead to homicide.

In the case of altered sexual behavior, the drugs might disinhibit we are told. They might – and this could give rise to some of the cases reported of female schoolteachers seducing their male pupils. But we have had far more reliably disinhibiting drugs than the SSRIs for decades and nothing comparable has been reported on them. We have had alcohol, benzodiazepines and other drugs with nothing comparable to this. We even have antidepressants that don’t act on the serotonin system – and they don’t generate reports like this.

What we also have are endless social commentaries on the psychopharmacological era that portray the benzodiazepines, mother’s little helpers, as sedating women into suburban prisons. These uniformly fail to take into account the biological reality of these drugs – that they undo conditioned avoidance and may well have done a great deal to upset social hierarchies in the 1960s.

Stories or more?

So how might we test these claims about changes in orientation? One suggestion has been that it will need a controlled trial. This is entirely wrong. For complex behaviors such as suicide where drugs can have suicide relieving and suicide provoking effects, controlled trials are worse than useless. The same will be true for complex sexual behaviors (See links).

We can qualitatively interview people – but will the skeptics be any more likely to believe the results of such interviews than alcoholics will believe Anne-Marie?

Unleashed

There is another group of drugs that come into play here – the dopamine agonists – Parlodel, Dostinex, Permax, Mirapex, Requip and Neupro. These are used for Parkinson’s disease – but also for Restless Legs. From soon after the first of these drugs appeared, there were reports of people becoming compulsive gamblers or turning to prostitution or leaving their partners of many years standing, sometimes for members of the opposite sex. Appeals to those affected this way to recognize the effects of the drugs get nowhere. There is something about what happens that is not recognizable to the person taking the pills.

This is not disinhibition. The behaviors in these cases are often stereotyped and compulsive. There is little room here for attributions or social constructions. Messing with the dopamine system disturbs reward hierarchies – and in some cases that can come fairly close to changing who we are, not just changing our sexual orientation.

Twenty years after the first reports, it is now recognized that one in six patients who go on dopamine agonists will have significant changes of behavior in one or other of these domains, and many will have quite disastrous effects. This drug group are widely available on a black market for sexual purposes but astonishingly the FDA data contain vanishingly few reports of any sexual effects on them, even though short of death these are about the most dramatic treatment induced effects there can be.

Does biology speak?

I routinely see transgender patients in North Wales where many of my colleagues will not. These patients are an astonishingly varied group of people. I have no difficulty in seeing some transgender cases as resulting from a change in how we construct identities since the nineteenth century. But being in a room with a transgender patient and having to make a judgment call on what happens next is an entirely different experience to being in a room with someone who has the rampant promiscuity and change of orientation seen on dopamine agonists and in some cases on SSRIs.

Nor am I averse to a role for some social constructions in adverse events. In my first publication on antidepressants and suicide I made it clear that part of the problem might lie in people making misattributions to what was going on and that warnings and knowledge were important as they could be used to reduce the risk by tackling misattributions.

But the idea that an unexpected drug induced “adverse” event is socially constructed pure and simple seems a contradiction in terms. What’s surprising is that many people seem to know beforehand what in fact is going on – its disinhibition. This sounds all too like the misconstruction of the benzodiazepines. A social account that pays no heed to biology is likely to be wrong.

Why bother?

Is it irresponsible to talk about these issues without nailing the “facts” down? When hundreds of thousands of adolescents are being put on serotonin reuptake inhibiting drugs is it irresponsible not to raise the issue? They are not being put on dopamine agonists but they are being put on the closely related psychostimulants. These drugs are having an impact on them while they are grappling with a sexual maturation process. We have no idea what this means.

Better surely have some place where people can go and access some kind of information on these possibilities than have nothing. Perhaps also those who access RxISK and find they are not alone can teach us all something. Might be fun just to see the Heatmap take shape.

Comments

I read this far too early in the day, the shoddy pseudoscience, logical fallacies, complete and utter lack of evidence and conspiracy paranoia is going to hinder my morning work, since I think my brain is about to fall out.

This fits in with early comment in the twittersphere. Hard to know what Eshto read. Its indisputable that AD’s have profound effects on sex – reduced ova and sperm, loss of libido, altered orgasm and erections. Its also indisputable that we know little of what might be happening in this domain. Why not? Pharma companies have known about this for forty years or more. Its not a matter of logic. Its a matter of data – the question is who might be scared to look

In Bruno Schulz’s work, God created the world and on the sixth day reached down to feel his creation – but retired baffled by what he felt. This is an area where collectively we cannot afford to retire baffled.

This post reminds me of a French man who became a gay sex addict on a Parkinsons drug, he took the Drug Company to court and won his case. I feel very sorry for him and his family they must have gone through a horrific time. Heres the story:
‘My life was hell’: Loving husband who said Parkinson’s drug made him a ‘gay sex addict’ awarded £160,000 by French court

Before he was diagnosed with Parkinson’s disease, Didier Jambart of western France, had been a well respected man, and a loving father and husband.

Fascinating post the most frightening aspect being putting teens on these drugs. I fear that drugs are being given for old fashioned teen angst, hormone driven, with unpredictable results. Parents and doctors have been convinced that ssris are safe and effective. Here in the states it is my understanding drug companies do not have to publish negative research results for physician edification. Even if reported to the FDA, half of the FDAs budget comes from drug companies. Terrible conflict of interest. Conspiracy Eshto? So suicides and homicides are not happening? Nor the panoply of side effects? We never ever hear whether school shooters were taking an anti depressant. Why is that? Autopsies look at organic brain structure which is invariably normal and that is dutifully reported by journalists. Mothers and fathers are blamed but never the drugs shooters may have been taking. Journalists haven’t thought to ask??

“Mind altering drugs” always alter the mind and very often the behavior. People who use drugs for recreational purposes make very strange and capricious bedfellows.

Many years ago (when I had a little experience with recreational drug use) I remember dating a man who seemed to me a very heterosexual guy. Thing was, he had a terrible cocaine habit, the depth of which I had little comprehension at the time. Anyway, I was a very pretty heterosexual young lady and we were out on a date one night. While walking down the street, a very glammed up transvestite walked by. “Isn’t she beautiful?” he proclaimed. I said “That is a man”. “Yes but she’s beautiful. Let’s go over and talk to her!” he said. I said we were going home and as the weeks wore on our relationship deteriorated because of his terrible habit. God only knows what else he did in the intervening years. Eventually he kicked his habit, left town and now lives elsewhere with a wonderful woman. He was really a very normal guy in many respects, but another animal altogether when using cocaine.

I am and always have been a heterosexual woman who has seen first hand the effects of these powerful drugs on sexual choices and behavior. I steer clear of people who toy with these substances as they make very unpredictable partners. SSRI, dopamine – whatever. To be used under smart medical supervision for seriously necessary cases only. They are powerful mind altering substances.

Same here. Ive read many comments of people feeling depressed and turning gay. Some of them develloped HOCD and even gender identity crisis, but when they took ssri they were cured after a month and felt they got their real identity back. It happened to me as well, but after 3 weeks of ssri it was gone. I then quit ssri, it came back. Now im working on raise naturally my serotonine level, to clear the brain fog and the hocd/depression.

While we’re looking at sexuality, it would also be worth looking in to SSRI use and the development of paraphilias.
While SSRI’s have been used to treat paraphilias in some individuals (no doubt by killing the libido), it would be interesting if paraphilias (or other abnormal sexual mindsets) could develop as the result of prolonged SSRI use. If so, could SSRI-induced sexual dysfunction and general indifference / apathy play a role?

Hi Mike,
Increasingly, a link is being established between the monoamines and “paraphilias”. I have briefly looked at some of Martin Kafka’s work on this, and there seems to be evidence linking the two on a number of lines, including co-morbidity with things like OCD, autism-spectrum disorders, anxiety and similar neurological issues. There are also reports of medications such as dopamine agonists (used to treat Parkinson’s) can trigger paraphilic thoughts/urges in some people. Withdrawal from the drug sees the thoughts/urges disappear again. Given that SSRI’s have had some success in the treatment of paraphilias, it also stands to reason there is a link. However, there is a growing body of evidence and reports on the internet (and in literature) illustrating a great variance in the side effect profiles and behavioural changes attributable to SSRI use. Many report libido problems. Some people online report “sexuality” changes. Some report changes in their sexual fantasy tastes. If the monoamines do control or influence sexual “tastes” (not necessarily orientation, but it’s possible), it stands to reason that, given that people respond differently to the drugs, there will be a subset of SSRI users that have their sexual tastes altered because of interference with their serotonin, dopamine, norephinephrine (etc) levels. When you look at what behaviours and functions 5HT (serotonin) receptors govern alone, you can see how such a wide variety of behaviors can be manipulated by one pill. It has also been noted that SSRI’s such as paroxetine “hijack” dopamine receptors. Who knows what implications could arise from this in some people – particularly over a long term?

SSRI’s may result in frontal lobe syndrome or disturbances in some people. Paraphilias have also apparently been linked to frontal lobe syndromes, so it’s plausible to assume the use of these meds could lead to the development of paraphilias in susceptible individuals, while suppressing them in others. I guess everybody reacts to the meds differently.

While the cases mentioned aren’t about paraphilias per se, they demonstrate that risky, disinhibited (possibly deviant?) sexual behaviors can possibly be triggered on paroxetine after an initial dip in sexual drive.

My now 15 year old son’s mild ocd became severe last year. Initially, he did not respond to 25 nor 50 mgs of zoloft. After having read that the antibiotic minocycline showed vast improvements in ocd symptoms in clinical trials, I had a willing and caring psychiatrist prescribe it to him. He put my son on 100 mgs 1x daily, as well as increased his zoloft to 200 mgs daily. What the medicine did for his severe, debilitating ocd symptoms was nothing short of amazing. He has now been on both medicines for coming close to a year now. Everything was great, at first, but in the last few months, however, their has been a change in sexual preference. He now thinks he’s bisexual. Prior to the medicine, he had always had crushes on nothing but girls. Albeit he was and is young, 15 now, he did everything he could did get a girl to like him, “dating” one girl after another…yes, puppy love….but nevertheless girls. With this sudden change, I started to research the effects of ssri’s and the effects of long term antibiotic use on sexual preference. Hence, coming across this article. Regardless of preference, I love my son no matter what….but without any indicators growing up…i can’t help but to wonder the possible drug-brain connection to this sudden switch. My son is open to test if either medicine has caused this. I plan on speaking to his psychiatrist to see if we can begin lowering his zoloft to see if there is a change. Tell me your thoughts.

Hi Lisa,
Sorry to hear your son is finding things tough sexuality-wise at 15. Of course, he is at the age where young people question their sexuality and experiment to begin with. However, there is also a chance that these changes reflect a type of sexual disinhibition that is sometimes seen on these medications. If the latter is the case, I don’t believe it’s bisexuality at all. Changes to serotonin levels have been implicated in changing sexual behavior, not so much changing sexual preference, but perhaps “removing” it somewhat (probably temporarily), hence apparent bisexuality. Of course, this is relying on experiments with mice and anecdotal reports from others. This isn’t to say stop taking the meds – they can and do work wonders for many people (including your son), but they can and do have strange effects many will not yet acknowledge.